Anatomical and Ultrasonography‐Based Investigation to Localize the Arteries on the Central Forehead Region During the Glabellar Augmentation Procedure

Abstract

Glabellar augmentation is one of the most popular cosmetic procedures but can entail severe complications caused by inadvertent intravascular injection of filler. Nevertheless, few studies have investigated the arteries on the glabellar and central forehead regions. The aim of this study was to correlate the topography and location of the arteries in this area with anatomical landmarks to propose a safety guideline. Two methods were used to investigate the glabellar and central forehead areas: dissection of 19 Thai embalmed cadavers, and ultrasonographic examination of 14 healthy Thai volunteers. At the level of the glabellar point, the horizontal distances from the midline to the arteries were 4.7 mm (central artery), 7.8 mm (paracentral artery), and 14.7 and 19.2 mm (superficial and deep branches of supratrochlear artery). The depths from the skin of the arteries were 3.1 mm (central artery), 4.8 mm (paracentral artery), and 4.2 and 5.9 mm (superficial and deep branches of supratrochlear artery). The periosteal artery was detected in 71.1% as a branch of either the superior orbitoglabellar or the supratrochlear artery. It ran in the supraperiosteal layer for a short course and penetrated the periosteum above the superciliary ridge or above the medial eyebrow, adhering tightly to the bony surface. This study suggests a safe injection technique for the glabella based on a thorough knowledge of arterial distribution and topography and color Doppler ultrasonographic examination prior to the injection, which is recommended to minimize the risk of severe complications. Clin. Anat. 33:370–382, 2020. © 2019 Wiley Periodicals, Inc.

CHAP-Hyaluronic Acid (CHAP-HA) Filler as an Optimal Candidate for Forehead Filler Augmentation Using a 3-Point Injection Technique

“…Various materials have been proposed for use in minimally invasive forehead augmentation, such as autologous fat, HA fillers, calcium hydroxyapatite, and combinations of these [2] [5] [6] [7]. In our study, CHAP-HA Blink was selected for its low G' and viscosity, superior moldability, and shape retention capacity.…”

“…Nonetheless, there is no consensus on injection technique for safe forehead augmentation. For injections into the glabella, Phumyoo et al suggested a safe technique based on topography, a thorough understanding of arterial distribution, and color Doppler ultrasonographic examination before injection to minimize the risk of severe complications [2]. Kim proposed a novel forehead classification system based on East Asian ethnicity and suggested that first injecting a tumescent solution and then using a minimal number of entry points for the injection of filler reduces the risk of embolization [5].…”

Usefulness of Doppler sonography in aesthetic medicine

“…ultrasound allows visualization of arteries with a diameter ≥ 0.3 mm. However, the authors used a linear transducer with a frequency of up to 12 MHz (14) . It seems that the use of a transducer with a higher frequency (18-22 MHz) allows for visualization of vessels with a diameter of about 0.1 mm.…”

Facial vascular danger zones for filler injections

“…At the level of the glabellar point, the horizontal distances from the midline to the arteries were 4.7 mm (central artery), 7.8 mm (paracentral artery), and 14.7 and 19.2 mm (superficial and deep branches of supratrochlear artery). The depths from the skin of the arteries were between 3.1 mm (central artery) and 5.9 mm (deep branches of supratrochlear artery) 11 …”

“…Injections on the nose had a high risk of vascular compromise of ophthalmic artery, while injections of the glabella more often resulted in central retinal artery compromise 13 . These studies suggest that glabellar augmentation with filler injection is one of the most dangerous procedures 11 …”